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from the book How to Have a
Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
Previous page: The
Tubal Connection (Page 1)
Next page: Ovulation -- Normal and
Abnormal
Table of Contents
How is tubal microsurgery performed ?
What are the risks of tubal surgery ?
Once the doctor has assessed the damage and pinpointed the location
of the blockages he will decide on treatment alternatives and how
to proceed. The first choice in the past used to be an attempt at
surgery to repair the tubal damage. However, because results with
tubal surgery were not very encouraging, many patients with tubal
damage are now advised to undergo IVF (in vitro fertilization) as
their first treatment option.
In order to select between IVF and tubal surgery,
we need to differentiate between intrinsic tubal damage and peritubal
damage. If the tubes have been damaged because of a problem outside
the fallopian tubes, such as peritubal adhesions or endometriosis,
which have caused the tubes to get kinked, then surgery may be useful.
However, surgery is not advisable for patients if the tubes have
been blocked because of TB; the tubes are very badly damaged; if
the tubes are blocked at multiple places; or if the tubes have been
blocked because of intrinsic tubal disease.
The likelihood of surgical success (in terms of
pregnancy), depends on the severity of the tubal damage. If a previous
infectious process has caused scarring of the fallopian tube, the
inner delicate lining may have become irreversibly damaged. All
operations can result in re-establishing patency in some cases -
but the main aim of the surgery is not to just open the tubes, but
to achieve pregnancy - and the tubes have to become capable of capturing
the egg and transporting it to the uterus for this to happen. Unfortunately,
surgery cannot reverse tubal damage once this has occurred.
What if only one tube is blocked? One normal tube
is sufficient to allow a pregnancy - and most surgeons would not
advise tubal surgery for these patients. Obviously, the chances
of pregnancy for such patients is half that of normal women and
therefore establishing a pregnancy may take twice as long. The danger
of trying to surgically repair a single blocked tube is that adhesions
because of the surgery may cause both the tubes to become blocked
!
How is tubal microsurgery performed ?
Microsurgery entails the use of the following surgical techniques:
- Using a microscope (for adequate magnification)
- Avoiding unnecessary trauma to the tissues
- Employing delicate surgical instruments
- Employing fine suture (stitching) material
and ensuring precise suturing
- Handling tissues with great care and respect,
to minimize tissue damage
- Ensuring that no bleeding is left unattended
and no clots are left behind (because this can lead to the formation
of adhesions or scar tissue after the surgery)
The microsurgery operation may take from 1 to
4 hours. Depending on the extent of pelvic damage and is usually
done under spinal or general anesthesia. The incision used is usually
a "bikini cut" (Pfannensteil incision) The length of stay
in hospital is usually 3 to 7 days. Tubal microsurgery can be expensive
and may cost up to Rs.40,000. Sometimes a "check or second-look
laparoscopy " is performed about one week after surgery to
ensure that tubal patency is maintained and to remove any small
adhesions that may have started to re-form.
The tubal obstruction could be at the uterotubal junction and this
is called a cornual block. The conventional surgical repair of cornual
blocks involved reimplanting the tube into the uterus - and had
dismal success rates. However, with microsurgery, it is possible
to see the very fine ends of the tubes under high magnification
and to join them together. This has a pregnancy rate of about 50%,
since the function of the rest of the tube is basically intact.
Recently, doctors have realized that a number
of patients have cornual blocks because of the presence of mucus
plugs and debris in the very fine cornual segment of the tubes.
Newer nonsurgical methods have now been devised to treat this. These
involve the passage of a fine guide wire or a fine balloon into
the cornual end of the tube through the uterus. This is called a
"balloon tuboplasty" or "cornual recanalisation,"
and can be done under ultrasound guidance; hysteroscopic guidance;
or fluoroscopic (X-ray) guidance. This is a significant advance,
since it saves patients the need for major surgery; and also has
excellent pregnancy rates.
This procedure entails division of adhesions surrounding the tubes.
When no other damage is apparent, success rates may be as high as
65%.
These include a variety of procedures which involve removing the
damaged portion of the tubes and rejoining the healthy ends of the
tube together . Success rates vary according to the area of damage
but are usually within the range of 20 - 50%.The chances of success
are higher when the defect occurs in the middle section of the tube.
If the tubes have been severely damaged and have formed a hydrosalpinx
(in which the fimbriae stick to one another and the tube is closed
off) the surgery required is called neosalpingostomy, in which the
surgeon opens the hydrosalpinx and creates a new opening for the
repaired tube. While this is technically easy, success rates are
very poor (about 20%) because the physiologic functioning of the
fimbriae rarely returns to normal.
If the damage is less severe (fimbrial agglutination,
in which the fimbriae are stuck to one another; or phimosis, in
which the tube is narrowed, but open), then surgical repair is more
successful, with pregnancy rates being about 50%.
What are the risks of tubal surgery ?
The risk of having an ectopic (tubal) pregnancy
is increased following tubal surgery. Fallopian tubes which have
been operated on may have a damaged inner lining, and this can impair
the movement of the embryo down the tube. This is why, in patients
who have had tubal surgery, the diagnosis of a pregnancy should
be made as soon as possible (preferably within a few days of missing
a menstrual period), to rule out the possibility of an ectopic pregnancy.
The best chance of success is with the first surgical
operation; therefore, you need to go to a specialized centre. The
chances of success will depend upon the extent of tubal damage and
also on the skill of the surgeon. The best chance of achieving a
pregnancy is in the surgeon. The best chance of achieving a pregnancy
is in the first few months after surgery, and most women who are
going to get pregnant after tubal surgery will conceive within this
time. Some doctors believe that using ovulation induction and /
or intrauterine insemination after tubal surgery helps to maximize
the chances of a pregnancy.
If the patient has not conceived within one year
after the surgery, then follow-up testing in the form of an HSG
and / or laparoscopy is advisable, to determine whether the fallopian
tubes are still open.
If the first surgery has been unsuccessful, the
chance of success as a result of reoperation is very low, and IVF
is the only treatment choice for such patients.
In the future, it is possible that tubal transplants
may become a reality and that scientists may also develop artificial
synthetic tubes to replace damaged ones.
With operative laparoscopy, it is now possible
to open damaged tubes through the laparoscope, thus saving the patient
major surgery. A hydrosalpinx can be repaired by opening it with
a laser or cautery and then keeping it open with sutures: and even
the complicated operation of tubal reanastomosis has been performed
by experienced surgeons through the laparoscope (using sutures or
special adhesive glue). However, the results with this surgery
are often poor, because these damaged tubes often do not function
properly even after the surgery.
Fig 4. Schematic showing damaged fallopian tubes because of pelvic
inflammatory disease ( PID). The left tube has formed a hydrosalpinx;
and the right is engulfed in peritubal adhesions.
Fig 5. Operative laparoscopy, during which an adhesion is being
divided (adhesiolysis)
In women, sterilization for family planning is usually done through
an operation called tubal ligation, which is usually carried out
through the laparoscope. The aim of the operation is to block the
tubes and prevent the sperm and egg from meeting each other.
The vast majority of people are very happy with sterilization. Nevertheless,
there are a few women who are very distressed afterwards and would
do almost anything to get things undone. The commonest reason why
such women regret sterilization is because their child dies or because
they have remarried and wish to bear their new husband’s child.
If there is a reasonable amount of tube remaining, even if only
on one side, then it may be possible to perform tubal microsurgery
to rejoin the tubes. On the whole, the more tube which has been
left undamaged, the better the chances of success. Thus, patients
who have had a tubal ligation done through the laparoscope, using
Falope rings (silastic bands) or clips, have an excellent chance
of achieving a pregnancy after microsurgical reversal of the ligation,
because these methods cause minimal tubal damage.
After reviewing the operative notes, a laparoscopy
may be advised, so that the exact state of the fallopian tubes can
be assessed. If the patient has enough normal tube, tubal microsurgery
may be attempted and pregnancy rates can be as high as 75% in favorable
cases. Some skilled surgeons can even perform this type of tubal reanastomosis
through the laparoscope (using sutures or
special adhesive glue). If, unfortunately, the patient has had both tubes completely
removed or if the tubes are very badly damaged, then the only chance
of success will be with IVF.
Most patients who will conceive after tubal
reanastomosis will do so within 1 year. If they do not, then the
next step for them would be IVF.
Next page: Ovulation
-- Normal and Abnormal
Previous page:
The Tubal Connection (Page 1)
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